Clinical Endoscopy

Original Articles

Usefulness of a new polyvinyl alcohol hydrogel (PVA-H)-based simulator for endoscopic submucosal dissection training: a pilot study: Dong Seok Lee, Gin Hyug Lee, Sang Gyun Kim, Kook Lae Lee, Ji Won Kim, Ji Bong Jeong, Yong Jin Jung, Hyoun Woo Kang; Clin Endosc 2023;56(5):604-612. Published online May 18, 2023; DOI: https://doi.org/10.5946/ce.2022.163

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Background
/Aims: We developed a new endoscopic submucosal dissection (ESD) simulator and evaluated its efficacy and realism for use training endoscopists.
Methods
An ESD simulator was constructed using polyvinyl alcohol hydrogel sheets and compared to a previous ESD simulator. Between March 1, 2020, and December 30, 2021, eight expert endoscopists from three different centers analyzed the procedure-related factors of the simulator. Five trainees performed gastric ESD exercises under the guidance of these experts.
Results
Although the two ESD simulators provided overall favorable outcomes in terms of ESD-related factors, the new simulator had several benefits, including better marking of the target lesion’s limits (p<0.001) and overall handling (p<0.001). Trainees tested the usefulness of the new ESD simulator. The complete resection rate improved after 3 ESD training sessions (9 procedures), and the perforation rate decreased after 4 sessions (12 procedures).
Conclusions
We have developed a new ESD simulator that can help beginners achieve a high level of technical experience before performing real-time ESD procedures in patients.

Citations

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There is no royal road: a shortcut for endoscopic submucosal dissection training
Seong Woo Jeon
Clinical Endoscopy.2023; 56(5): 590. CrossRef

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Efficacy of an assistive guide tube for improved endoscopic access to gastrointestinal lesions: an in vivo study in a porcine model: Dong Seok Lee, Jeong-Sik Byeon, Sang Gyun Kim, Ji Won Kim, Kook Lae Lee, Ji Bong Jeong, Yong Jin Jung, Hyoun Woo Kang; Clin Endosc 2024;57(1):82-88. Published online April 18, 2023; DOI: https://doi.org/10.5946/ce.2022.161

Graphical Abstract Abstract PDF PubReader ePub: Background
/Aims: Guide tube-assisted endoscopy for procedures that require repeated endoscopic access is safer and more effective than conventional endoscopy. However, its effectiveness has not been confirmed in animal studies. We assessed the usefulness of guide tube-assisted endoscopic procedures in an in vivo porcine model.
Methods
Five different guide tube-assisted endoscopic procedures were performed by experienced endoscopists on a pig weighing 32 kg. To evaluate the efficacy of these procedures, we compared the endoscopic approach time when a guide tube was used to that when it was not. Additional endoscopic procedures using a guide tube were performed, including multiple foreign body extractions, multiple polypectomies, and multiple submucosal dissections. To evaluate safety, we compared the insertion force into the proximal esophagus between the guide tube and conventional overtube methods.
Results
Using the endoscopic approach with a guide tube required a shorter average approach time to reach the three target lesions than when using the endoscopic approach without a guide tube (p<0.001). Compared to the conventional overtube method, the guide tube method produced a lower average resistance during insertion into the upper esophagus (p<0.001).
Conclusions
Guide tube-assisted endoscopic procedures are effective and safe for repeated endoscopic access in an in vivo porcine model.

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Focused Review Series: Recent Update of Endoscopic Ultrasonography in Gastrointestinal Subepithelial Tumors

Current Status of Endoscopic Ultrasonography in Gastrointestinal Subepithelial Tumors: Sang Gyun Kim, Ji Hyun Song, Joo Ha Hwang; Clin Endosc 2019;52(4):301-305. Published online July 9, 2019; DOI: https://doi.org/10.5946/ce.2019.024

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Gastrointestinal subepithelial tumors (GSTs) are usually detected incidentally on endoscopic or radiologic examinations. In conventional endoscopy, a GST usually presents as a protuberant lesion with an intact mucosal surface. As the lesion is located beneath the mucosal layer of the gastrointestinal tract, conventional biopsy typically does not reveal the pathologic diagnosis. First, a GST should be differentiated from an extrinsic compression through the positional change of the patient during conventional endoscopic examination. In cases of GSTs originating from the gastrointestinal wall, endoscopic ultrasonography (EUS) can be beneficial for narrowing the differential diagnosis through delineation of echo findings and by determining the layer of origin. EUS findings can also help determine the management strategies for GSTs by making a differential diagnosis according to malignant potential.

Citations

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Endoscopic Resection of Upper Gastrointestinal Subepithelial Tumours: Our Clinical Experience and Results
Mehmet Zeki Buldanlı, Oktay Yener
Prague Medical Report.2022; 123(1): 20. CrossRef
Gastric subepithelial tumor: long-term natural history and risk factors for progression
Bokyung Kim, Seungkyung Kang, Eunwoo Lee, Jinju Choi, Hyunsoo Chung, Soo-Jeong Cho, Sang Gyun Kim
Surgical Endoscopy.2022; 36(7): 5232. CrossRef
Traumatic neuroma of remnant cystic duct mimicking duodenal subepithelial tumor: A case report
Dong-Hwan Kim, Ji-Ho Park, Jin-Kyu Cho, Jung-Wook Yang, Tae-Han Kim, Sang-Ho Jeong, Young-Hye Kim, Young- Joon Lee, Soon-Chan Hong, Eun-Jung Jung, Young-Tae Ju, Chi-Young Jeong, Ju-Yeon Kim
World Journal of Clinical Cases.2020; 8(17): 3821. CrossRef

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Review

Treatment Strategy after Incomplete Endoscopic Resection of Early Gastric Cancer: Sang Gyun Kim; Clin Endosc 2016;49(4):332-335. Published online July 20, 2016; DOI: https://doi.org/10.5946/ce.2016.069

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Endoscopic resection of early gastric cancer is defined as incomplete when tumor cells are found at the resection margin upon histopathological examination. However, a tumor-positive resection margin does not always indicate residual tumor; it can also be caused by tissue contraction during fixation, by the cautery effect during endoscopic resection, or by incorrect histopathological mapping. Cases of highly suspicious residual tumor require additional endoscopic or surgical resection. For inoperable patients, argon plasma coagulation can be used as an alternative endoscopic treatment. Immediately after the incomplete resection or residual tumor has been confirmed by the pathologist, clinicians should also decide upon any additional treatment to be carried out during the follow-up period.

Citations

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Long-term Outcomes of Patients With Early Gastric Cancer Who Had Lateral Resection Margin-Positive Tumors Based on Pathology Following Endoscopic Submucosal Dissection
Jun Hee Lee, Sang Gyun Kim, Soo-Jeong Cho
Journal of Gastric Cancer.2024; 24(2): 199. CrossRef
Clinico-pathologic determinants of non-e-curative outcome following en-bloc endoscopic submucosal dissection in patients with early gastric neoplasia
Kidane Siele Embaye, Chao Zhang, Matiwos Araya Ghebrehiwet, Zhihao Wang, Fengdi Zhang, Liwei Liu, Shenghui Qin, Lingzhi Qin, Jun Wang, Xi Wang
BMC Cancer.2021;[Epub] CrossRef
Risk Factors and Clinical Outcomes of Non-Curative Resection in Patients with Early Gastric Cancer Treated with Endoscopic Submucosal Dissection: A Retrospective Multicenter Study in Korea
Si Hyung Lee, Min Cheol Kim, Seong Woo Jeon, Kang Nyeong Lee, Jong Jae Park, Su Jin Hong
Clinical Endoscopy.2020; 53(2): 196. CrossRef
Long-term outcomes after noncurative endoscopic resection of early gastric cancer: the optimal time for additional endoscopic treatment
Mi Young Jeon, Jun Chul Park, Kyu Yeon Hahn, Sung Kwan Shin, Sang Kil Lee, Yong Chan Lee
Gastrointestinal Endoscopy.2018; 87(4): 1003. CrossRef
Prediction model for non-curative resection of endoscopic submucosal dissection in patients with early gastric cancer
Eun Hye Kim, Jun Chul Park, In Ji Song, Yeong Jin Kim, Dong Hoo Joh, Kyu Yeon Hahn, Yong Kang Lee, Ha Yan Kim, Hyunsoo Chung, Sung Kwan Shin, Sang Kil Lee, Yong Chan Lee
Gastrointestinal Endoscopy.2017; 85(5): 976. CrossRef

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Original Article

Efficacy of Albis for the Prevention of Gastric Mucosal Injury Concomitant with the Use of Low-Dose Aspirin: A Prospective, Randomized, Placebo-Controlled Study: Sang Gyun Kim, Nayoung Kim, Sung Kwan Shin, In Kyung Sung, Su Jin Hong, Hyo-Jin Park; Clin Endosc 2017;50(2):179-184. Published online May 19, 2016; DOI: https://doi.org/10.5946/ce.2016.031

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Background
/Aims: Long-term use of aspirin can be a risk factor of peptic ulcer diseases. The aim of this study was to evaluate the efficacy of Albis (Daewoong Pharmaceutical Co., Ltd.) for the prevention of gastric mucosal injury caused by aspirin.
Methods
Aspirin users were enrolled and randomized into the Albis or placebo group. Screening and follow-up endoscopy were performed for modified Lanza scores (MLSs). Primary outcome was measured by the incidence rate of peptic ulcer, and secondary outcomes were measured by the incidence rate of gastritis, improvement in MLS and subjective symptoms.
Results
In total, 81 aspirin users were randomized, 43 in the Albis group and 38 in the placebo group. There was no incidence of peptic ulcer in both groups. The incidence of gastritis was significantly higher in the placebo group (44.4% vs. 10.0%, p=0.003); however, the scores of mucosal edema, hyperemia and hemorrhage were not statistically different between the two groups (p>0.05). The frequency of subjective symptoms were more improved in the Albis group than in the placebo group (p=0.023).
Conclusions
The incidence of gastritis was lower in the group that received low-dose aspirin and Albis. The development of peptic ulcer due to long-term use of aspirin might be prevented with concomitant use of Albis.

Citations

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Xiaojianzhong decoction attenuates gastric mucosal injury by activating the p62/Keap1/Nrf2 signaling pathway to inhibit ferroptosis
Juan Chen, Jiaxiang Zhang, Ting Chen, Shengchuan Bao, Jingtao Li, Hailiang Wei, Xin Hu, Yan Liang, Fanrong Liu, Shuguang Yan
Biomedicine & Pharmacotherapy.2022; 155: 113631. CrossRef
A measure of asymmetry for ordinal square contingency tables with an application to modified LANZA score data
Satoru Shinoda, Kouji Yamamoto, Kouji Tahata, Sadao Tomizawa
Journal of Applied Statistics.2020; 47(7): 1251. CrossRef

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Focused Review Series: Advances in the management of upper GI SET

Interpretation of Pathologic Margin after Endoscopic Resection of Gastrointestinal Stromal Tumor: Sang Gyun Kim; Clin Endosc 2016;49(3):229-231. Published online April 7, 2016; DOI: https://doi.org/10.5946/ce.2016.035

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Interpretation of the pathologic margin of a specimen from a resected tumor is important because local recurrence can be predicted by the presence of tumor cells in the resection margin. Although a sufficient resection margin is recommended in the resection of gastrointestinal adenocarcinoma, it is not usually regarded strictly in cases of mesenchymal tumor, especially gastrointestinal stromal tumor (GIST), because the tumor is usually encapsulated or well demarcated, and not infiltrative. Therefore, margin positivity is not rare in the pathological evaluation of surgically or endoscopically resected GIST, and does not always indicate incomplete resection. Although a GIST may have a tumor-positive pathologic margin, complete resection may be achieved if no residual tumor is visible, and long-term survival can be predicted as in the cases with a negative pathologic margin.

Citations

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Efficiency of an endoscopic resection strategy for management of submucosal tumors < 20 mm in the upper gastrointestinal tract
Fabrice Caillol, Elise Meunier, Christophe Zemmour, Jean-Philippe Ratone, Jerome Guiramand, Solene Hoibian, Yanis Dahel, Flora Poizat, Marc Giovannini
Endoscopy International Open.2022; 10(04): E347. CrossRef
Comparison of the treatment outcomes of endoscopic and surgical resection of GI stromal tumors in the stomach: a propensity score–matched case-control study
Ga Hee Kim, Kee Don Choi, Chung Sik Gong, In-Seob Lee, Young Soo Park, Minkyu Han, Hee Kyong Na, Ji Yong Ahn, Jeong Hoon Lee, Kee Wook Jung, Do Hoon Kim, Ho June Song, Gin Hyug Lee, Hwoon-Yong Jung
Gastrointestinal Endoscopy.2020; 91(3): 527. CrossRef
Is the Surgical Margin in Gastrointestinal Stromal Tumors Different
Piotr Rutkowski, Jacek Skoczylas, Piotr Wisniewski
Visceral Medicine.2018; 34(5): 347. CrossRef

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Focused Review Series: Updates on Gastrointestinal and Pancreaticobiliary Stents

Upper Gastrointestinal Stent Insertion in Malignant and Benign Disorders: Hyoun Woo Kang, Sang Gyun Kim; Clin Endosc 2015;48(3):187-193. Published online May 29, 2015; DOI: https://doi.org/10.5946/ce.2015.48.3.187

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Upper gastrointestinal (GI) stents are increasingly being used to manage upper GI obstructions. Initially developed for palliative treatment of esophageal cancer, upper GI stents now play an emerging role in benign strictures of the upper GI tract. Because recurrent obstruction and stent-related complications are common, new modifications of stents have been implemented. Self-expandable metal stents (SEMS) have replaced older plastic stents. In addition, newly designed SEMS have been developed to prevent complications. This review provides an overview of the various types, indications, methods, complications, and clinical outcomes of upper GI stents in a number of malignant and benign disorders dividing the esophagus and gastroduodenum.

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Reviews

Lymph Node Metastases in Esophageal Carcinoma: An Endoscopist's View: Jin Woong Cho, Suck Chei Choi, Jae Young Jang, Sung Kwan Shin, Kee Don Choi, Jun Haeng Lee, Sang Gyun Kim, Jae Kyu Sung, Seong Woo Jeon, Il Ju Choi, Gwang Ha Kim, Sam Ryong Jee, Wan Sik Lee, Hwoon-Yong Jung, Korean ESD Study Group; Clin Endosc 2014;47(6):523-529. Published online November 30, 2014; DOI: https://doi.org/10.5946/ce.2014.47.6.523

Abstract PDF PubReader ePub

One of the most important prognostic factors in esophageal carcinoma is lymph node metastasis, and in particular, the number of affected lymph nodes, which influences long-term outcomes. The esophageal lymphatic system is connected longitudinally and transversally; thus, the pattern of lymph node metastases is very complex. Early esophageal cancer frequently exhibits skipped metastasis, and minimal surgery using sentinel node navigation cannot be performed. In Korea, most esophageal cancer cases are squamous cell carcinoma (SCC), although the incidence of adenocarcinoma has started to increase recently. Most previous reports have failed to differentiate between SCC and adenocarcinoma, despite the fact that the Union for International Cancer Control (7th edition) and American Joint Committee on Cancer staging systems both consider these separately because they differ in cause, biology, lymph node metastasis, and outcome. Endoscopic tumor resection is an effective and safe treatment for lesions with no associated lymph node metastasis. Esophageal mucosal cancer confined to the lamina propria is an absolute indication for endoscopic resection, and a lesion that has invaded the muscularis mucosae can be cured by local resection if invasion to the lymphatic system has not occurred.

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Stricture Occurring after Endoscopic Submucosal Dissection for Esophageal and Gastric Tumors: Gwang Ha Kim, Sam Ryong Jee, Jae Young Jang, Sung Kwan Shin, Kee Don Choi, Jun Haeng Lee, Sang Gyun Kim, Jae Kyu Sung, Suck Chei Choi, Seong Woo Jeon, Byung Ik Jang, Kyu Chan Huh, Dong Kyung Chang, Sung-Ae Jung, Bora Keum, Jin Woong Cho, Il Ju Choi, Hwoon-Yong Jung, Korean ESD Study Group; Clin Endosc 2014;47(6):516-522. Published online November 30, 2014; DOI: https://doi.org/10.5946/ce.2014.47.6.516

Abstract PDF PubReader ePub

Endoscopic submucosal dissection (ESD) is a widely accepted treatment for early gastric and esophageal cancer. Compared to endoscopic mucosal resection, ESD has the advantage of enabling en bloc removal of tumors regardless of their size. However, ESD can result in a large artificial ulcer, which may lead to a considerable deformity. Circumferential mucosal defects of more than three-fourths the esophageal circumference, long longitudinal mucosal defects (>30 mm), and lesions in the upper esophagus are significant risk factors for the development of post-ESD strictures of the esophagus. In the stomach, a circumferential mucosal defects more than three-fourths in extent and longitudinal mucosal defects >5 cm are risk factors of post-ESD stricture. If scheduled early, regular endoscopic balloon dilation is effective in controlling and preventing post-ESD stricture. Moreover, intralesional steroid injections or oral steroids can achieve remission of dysphagia or reduce the need for repeated endoscopic balloon dilation. However, further study is needed to improve the prevention of stricture formation.

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Endoscopic submucosal dissection under general anesthesia for superficial esophageal squamous cell carcinoma is associated with better clinical outcomes
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Evidence-Based Recommendations on Upper Gastrointestinal Tract Stenting: A Report from the Stent Study Group of the Korean Society of Gastrointestinal Endoscopy: Sam Ryong Jee, Joo Young Cho, Kyung Ho Kim, Sang Gyun Kim, Jun-Hyung Cho, The Stent Study Group of the Korean Society of Gastrointestinal Endoscopy; Clin Endosc 2013;46(4):342-354. Published online July 31, 2013; DOI: https://doi.org/10.5946/ce.2013.46.4.342

Abstract PDF PubReader ePub

Endoscopic stents have evolved dramatically over the past 20 years. With the introduction of uncovered self-expanding metal stents in the early 1990s, they are primarily used to palliate symptoms of malignant obstruction in patients with inoperable gastrointestinal (GI) cancer. At present, stents have emerged as an effective, safe, and less invasive alternative for the treatment of malignant GI obstruction. Clinical decisions about stent placement should be made based on the exact understanding of the patient's condition. These recommendations based on a critical review of the available data and expert consensus are made for the purpose of providing endoscopists with information about stent placement. These can be helpful for management of patients with inoperable cancer or various nonmalignant conditions in the upper GI tract.

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Upper Gastrointestinal Stent: Sang Gyun Kim, Chang-Hun Yang; Clin Endosc 2012;45(4):386-391. Published online November 30, 2012; DOI: https://doi.org/10.5946/ce.2012.45.4.386

Abstract PDF PubReader ePub

Gastrointestinal (GI) stent has been developed for palliation of obstructive symptoms in various diseases causing obstruction of GI tract. Self-expanding metal stent (SEMS) has replaced old type of plastic stent, and endoscopic insertion of stent has replaced fluoroscopy-guided insertion. Nowadays, newly-designed SEMSs have been developed for prevention of complications such as stent migration and re-obstruction, and indications of stent recently have been widened into benign conditions as well as malignant obstruction. In this review, the types, method of insertion, indications and clinical outcomes of stent in the upper GI tract would be discussed.

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Special Issue Articles of IDEN 2012

Estimation by Gross Findings in Early Gastric Cancer: Sang Gyun Kim; Clin Endosc 2012;45(3):245-247. Published online August 22, 2012; DOI: https://doi.org/10.5946/ce.2012.45.3.245

Abstract PDF PubReader ePub

Endoscopic resection has been accepted as both minimally invasive and curative treatment modality for early gastric cancer (EGC). The widely accepted indication of endoscopic resection for EGC is small sized, differentiated mucosal cancer in which the risk of lymph node metastasis is negligible. Tumor size can be measured by conventional endoscopy, and chromoendoscopy, magnifying endoscopy, narrow band imaging, autofluorescence imaging can also be helpful for accurate estimation of tumor size. Pretreatment tumor histology can be assessed with endoscopic biopsy, and also be measured by confocal endomicroscopy (so called "virtual biopsy"). Although endoscopic ultrasonography may be helpful for the assessment of tumor depth in EGC, the accurate assessment of tumor depth can be performed by the typical findings in the conventional endoscopy, by which treatment modality can be decided according to the depth of tumor invasion.

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